Retooling the health-care system

As Canadians, we take justifiable pride in our health-care system with its long record of equitable coverage for most important services. If you become acutely ill and you live close to a major centre you will receive care that is as good as anywhere in the world.

But how good is our health care overall compared with the rest of the world?

In 2010, the New York-based Commonwealth Fund survey found that Canada ranked near the bottom in a seven-country comparison of several measures, including access, safety, equity and efficiency. A recent report in the Lancet compared burden-of-disease statistics in 19 OECD countries. In terms of life expectancy at birth, and years of life lost, Canada slipped from second to seventh and from fourth to 10th position, respectively, between 1990 and 2010, although all measures improved over time.

So what is the cause of Canada’s uncompetitive performance in health and health care and should it make us reconsider the way that we deliver services?

One major challenge is co-ordinating the care of chronic disease. Heart disease, stroke, chronic obstructive pulmonary disease and diabetes are leading causes of death in Canada. They affect more than one in three Canadians, have a major effect on health and quality of life and account for more than half of provincial health-care spending. However, the current structure and payment system, with heavy investment in hospitals, is designed for acute episodic care and copes poorly with the needs of chronic disease patients.

Fragmentation and poor co-ordination result in serious gaps in quality of care. Chronic disease management programs require a multidisciplinary approach designed to encourage adherence to medications and lifestyle changes, and promote patient self-management. Such programs can reduce complications, avoid costly readmissions to the hospital, and improve survival and quality of life.

Achieving these goals is difficult, as it requires co-ordination of care through teams of multidisciplinary professionals across different health-care sectors over a sustained period of time. Most provinces have deployed a range of primary care models to promote continuity and comprehensiveness of care, but these models have not integrated specialists and hospitals into care management teams.

So how can Canadian policy-makers implement more co-ordinated care? In a study published this week in Open Medicine, we argue that virtual multi-specialty networks may be a useful model of care delivery.

Virtual networks are informal, self-organizing systems consisting of primary care physicians, specialists, interdisciplinary health providers and the hospitals where their patients are admitted. We identified and characterized 78 multidisciplinary physician networks in Ontario. In the absence of any formal co-ordinating structure, they developed naturally through long-standing referral patterns, sharing of information, and admission of patients to the same hospitals.

The networks are large and stable, and each includes several primary care groups, many specialists and at least one hospital, all organized around a common patient population.

Physicians in such networks are associated by virtue of sharing care for common patients, admitting patients to the same hospitals, and sharing important resources that affect their patients’ outcomes. These networks are not formally constituted organizations and providers are typically unaware that they are part of one. Consequently, they lack advanced processes for sharing information and co-ordinating care. Yet strengthening these existing links may be an efficient way to build networks of providers that already have shared patients and long-standing relationships.

Self-organizing multidisciplinary networks could form the basis of “systems of care” that collectively serve their large panels of patients. They are sufficiently large to provide a range of health-care services, implement system improvements, and be held accountable for results.

Investments in better patient information-sharing systems, communication and collaboration protocols, and common performance metrics, combined with appropriate incentive payment structures that reward co-ordinated care, could help catalyze significant advances in care for patients with chronic disease. Importantly, they could also work in collaboration with public health units to deliver disease prevention programs.

Formal constitution of multi-specialty physician groups around existing patterns of patient flow could serve as a model for “accountable care systems” that aim to facilitate co-ordination of care at a local level for high-needs patients, as it is aligned with a systems-minded approach to providing long-term chronic disease care and prevention.

There’s one thing of which we are certain: maintaining the status quo is not sufficient for Canadians to retain pride in our health-care system. The time for reform is now.

Thérèse Stukel and David Henry are expert advisers with EvidenceNetwork.ca. Stukel is also a senior scientist at the Institute for Clinical Evaluative Sciences, Toronto, and adjunct professor at the Dartmouth Institute for Health Policy and Clinical Practice in Hanover, N.H. Henry is the CEO of the Institute for Clinical Evaluative Sciences and a professor in the Department of Medicine, University of Toronto.